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2028
Genitourinary Imaging

US of the Inguinal Canal: Com-

prehensive Review of Pathologic
Processes with CT and MR Imaging
Correlation1
Margarita V. Revzin, MD, MS
Devrim Ersahin, MD
Gary M. Israel, MD
Jonathan D. Kirsch, MD
Mahan Mathur, MD
Jamal Bokhari, MD
Leslie M. Scoutt, MD
Abbreviations: IC = inguinal canal, PV = pro-
cessus vaginalis
RadioGraphics 2016; 36:2028–2048
Published online 10.1148/rg.2016150181
Content Codes:
1
From the Department of Diagnostic Radiol-
ogy, Yale University School of Medicine, 333
Cedar St, PO Box 208042, Room TE-2, New
Haven, CT 06520. Recipient of a Certificate
of Merit award for an education exhibit at the
2014 RSNA Annual Meeting. Received June 13,
2015; revision requested September 13 and re-
ceived October 30; accepted February 3, 2016.
For this journal-based SA-CME activity, the au-
thor L.M.S. has provided disclosures (see end of
article); all other authors, the editor, and the re-
viewers have disclosed no relevant relationships.
Address correspondence to M.V.R. (e-mail:
margarita.revzin@yale.edu).
©
RSNA, 2016
SA-CME Learning Objectives
After completing this journal-based SA-CME
activity, participants will be able to:
■■Describe embryologic development
and relevant anatomic structures of the
IC in male and female individuals and
the relationships of these structures with
inguinal pathologic processes.
■■Determine proper US techniques for
imaging the IC.
■■Recognize US features of common and
uncommon pathologic processes involv-
ing the IC.
See www.rsna.org/education/search/RG.
Ultrasonography (US) has a fundamental role in the initial exami-
nation of patients who present with symptoms indicating abnor-
malities of the inguinal canal (IC), an area known for its complex
anatomy. A thorough understanding of the embryologic and imag-
ing characteristics of the contents of the IC is essential for any gen-
eral radiologist. Moreover, an awareness of the various pathologic
conditions that can affect IC structures is crucial to preventing
misdiagnoses and ensuring optimal patient care. Early detection
of IC abnormalities can reduce the risk of morbidity and mortality
and facilitate proper treatment. Abnormalities may be related to in-
creased intra-abdominal pressure, which can result in development
of direct inguinal hernias and varicoceles, or to congenital anoma-
lies of the processus vaginalis, which can result in development
of indirect hernias and hydroceles. US is also helpful in assessing
postoperative complications of hernia repair, such as hematoma,
seroma, abscess, and hernia recurrence. In addition, it is often the
modality initially used to detect neoplasms arising from or invad-
ing the IC. US is an important tool in the examination of patients
suspected of having undescended testes or posttraumatic testicular
retraction and is essential for the examination of patients suspected
of having torsion or infectious inflammatory conditions of the sper-
matic cord.
Online supplemental material is available for this article.
©
RSNA, 2016 • radiographics.rsna.org
Introduction
Ultrasonography (US) has an important role in the initial assessment
of pathologic processes of the inguinal canal (IC). It is critical for the
radiologist to understand the embryologic development and detailed
US-depicted anatomy of the IC to avoid misinterpretion of findings.
Moreover, awareness of the US appearances of a broad spectrum
of pathologic conditions affecting the IC will facilitate improved ac-
curacy in interpretation of findings and help ensure proper treatment
of patients.
In this article, we review the anatomy and embryologic devel-
opment of the IC, optimal US scanning techniques, and imaging
characteristics of both common and rare pathologic conditions of the
IC. In addition, US findings are correlated with the findings of other
imaging modalities.
RG  •  Volume 36  Number 7 Revzin et al  2029
Teaching Points
■■ An indirect inguinal hernia occurs when abdominal contents
protrude through the deep inguinal ring and course antero-
medially to the spermatic cord in the IC. The hernia contents
emerge by way of the superficial ring and often descend into
the scrotum or labia majora.
■■ The deep inguinal ring is the neck of an indirect inguinal her-
nia and is located lateral to the origin of the inferior epigastric
vessels. The neck of a direct inguinal hernia lies medial to the
inferior epigastric vessels within the Hesselbach triangle.
■■ There are two major types of IC hydrocele—communicating
and noncommunicating. With a communicating hydrocele,
there is communication of fluid between the peritoneal cavity
and scrotum due to complete patency of the PV.
■■ Isolated right-sided varicoceles are seen in only 6% of patients,
and if they are detected, the retroperitoneum and abdomen
should be evaluated for any pathologic process—most com-
monly a neoplasm.
■■ At imaging, nonpalpable testes can be localized by using
the tracking technique. With this technique, the sper-
matic cord is used as a guide to find the testes. Initially,
one can identify the spermatic cord in the IC at the deep
inguinal ring by scanning in a sagittal oblique plane on the
short axis relative to the IC. Once found, the cord can be
“tracked” inferiorly in an attempt to locate the testis along
the path of testicular descent.
Embryologic
Development of the IC
The ICs develop in both male and female indi-
viduals. The processus vaginalis (PV), an evagina-
tion of the parietal peritoneum, and the guber-
naculum, a fibromascular ligament, have major
roles in the development of the IC.
At 7 weeks gestation, the gubernaculum has
developed. In male embryos, the cranial end
of the gubernaculum is attached to the inferior
pole of the testes and the caudal end is attached
to the labioscrotal fold. The gubernaculum as-
sists in the descent of the testes from their intra-
abdominal position into the developing scrotum
(Fig 1) (1–3).
In female embryos, the cranial end of the
gubernaculum is attached to the ovaries and the
caudal end is attached to the internal surface of
the labioscrotal fold. Midpoint attachment of the
gubernaculum to the uterus prevents the ovaries
from descending into the ICs. The cranial portion
of the gubernaculum later becomes the ovarian
ligament, and the caudal portion becomes the
round ligament of the uterus. The round liga-
ments pass through the ICs and terminate in the
labia majora (1).
The PV, also known as the diverticulum of the
parietal peritoneum, develops during the 2nd and
3rd months of gestation and lies ventral to the
gubernaculum (Fig 1). The PV herniates through
the abdominal wall along a path formed by the
gubernaculum, and in male fetuses, it passes into
the developing scrotum. Extensions of the layers of
the abdominal wall accompany the PV and form
the walls of the IC. In male fetuses, these layers also
form the coverings of the spermatic cord and testes
(Fig 2). The opening of the transversalis fascia pro-
duced by the PV becomes the deep inguinal ring,
and the triangular opening in the external oblique
aponeurosis from which the PV emerges becomes
the superficial inguinal ring. The superior portion
of the PV usually closes at or just before birth, and
obliteration proceeds gradually in a downward
direction (Fig 2). In the male fetus, the scrotal por-
tion of the PV remains patent, forming the tunica
vaginalis of the testicle; in the female fetus, it de-
generates before birth. A persistently patent PV will
allow communication between the tunica vaginalis
and the peritoneal cavity. In female fetuses, a persis-
tently patent PV is called the canal of Nuck (4).
Normal
Anatomy of the IC
The IC is an oblique inferomedially directed 4-cm
passage that is lined by the aponeuroses of three
abdominal wall muscle groups (Fig 3). These
abdominal wall muscles form the anterior and
posterior walls, roof, and floor of the IC (Fig 4)
(5,6). The IC lies parallel and cranial to the medial
half of the inguinal ligament. The deep inguinal
ring marks the entrance to the IC and is produced
by an outpouching of the transversalis fascia. The
transversalis fascia continues into the canal, form-
ing the innermost covering (ie, internal fascia)
of the IC. The superficial inguinal ring, a slit-
like opening in the external oblique aponeurosis,
represents the exit site from the IC through which
the spermatic cord (in male persons) and round
ligament (in female persons) emerge and lies su-
perolateral to the pubic tubercle. The IC contains
blood, lymph vessels, and the ilioinguinal nerve
in both sexes, in addition to the spermatic cord in
male individuals and the round ligament in female
individuals (Fig 5) (4).
The inferior epigastric vessels represent one of
the major anatomic landmarks that help local-
ize the deep inguinal ring (7). They arise from
the external iliac artery and vein immediately
above the inguinal ligament, course in an upward
oblique direction along the medial margin of
the internal inguinal ring, and anastomose with
the superior epigastric vessels at the level of the
umbilicus. The deep inguinal ring is located just
lateral and slightly cranial to the origin of the
inferior epigastric artery. The Hesselbach triangle
represents an anatomic area defined medially by
the lateral border of the rectus abdominis muscle,
superolaterally by the inferior epigastric vessels,
and inferiorly by the inguinal ligament (8).
2030  November-December 2016 radiographics.rsna.org

Figure 1.  Diagram of the embryo-

logic development of the IC. A, At
7 weeks gestation, the gubernacu-
lum passes through the developing
anterior abdominal wall at the site
of the future IC. The gubernaculum
is attached to the lower pole of the
extraperitoneally located testes. B,
At 7–12 weeks gestation, the guber-
naculum shortens and pulls the tes-
tes to the level of the deep inguinal
ring. The PV invaginates through
the anterior abdominal wall along
a path formed by the gubernacu-
lum. Extensions of the layers of the
abdominal wall accompany the PV
and form the walls of the IC. C, At
26–28 weeks gestation, with andro-
genic stimulation and increased in-
tra-abdominal pressure, the PV and
testes begin to pass through the
IC. It takes 2–3 days for the testes
to reach the scrotum. D, At 32–40
weeks gestation, the IC is formed,
and there is downward gradual
obliteration of the PV. The scrotal
portion of the PV remains patent,
forming the tunica vaginalis.

Figure 2.  Diagram of the IC and

scrotum shows obliteration of the
superior portion of the PV. Dur-
ing development, extensions of
all layers of the abdominal wall
accompany the PV and contrib-
ute to the formation of the walls
of the IC and scrotum. The PV is
anterior (ventral) to the spermatic
cord and developing testis. The
parietal and visceral layers of the
tunica vaginalis are formed from
the patent scrotal portion of the
PV. The testes and spermatic cord
remain retroperitoneal throughout
their descent.

Anatomy of the Spermatic Cord Physiologic

The contents of the spermatic cord include the
ductus (vas) deferens, a 45-cm-long tube that trans-
ports sperm from the epididymis to the ejaculatory
duct; the testicular, cremasteric, and deferential
arteries and veins (pampiniform plexus); the genital
branch of the genitofemoral nerve, which supplies
the cremaster muscle; the lymphatic vessels; and
connective tissue. The pampiniform plexus is a net-
work of small veins that drain into the right or left
testicular veins..Sympathetic nerve fibers are present
on arteries and the ductus deferens. Fascial layers
from the three abdominal wall muscle aponeuroses
cover the spermatic cord (Fig 5) (6).
Features of the IC
In adults, the deep and superficial rings of the
IC do not overlap because of the oblique path
of the IC. In the healthy individual, increased
intra-abdominal pressure will force the posterior
wall of the IC against the anterior wall and thus
strengthen this wall and decrease the likeli-
hood of herniation. Contraction of the external
oblique muscle also brings together the anterior
and posterior IC walls and serves to maintain
the integrity of the IC. In addition, contraction
of the internal oblique and transverse abdominis
muscles causes the canal to constrict by causing
RG  •  Volume 36  Number 7 Revzin et al  2031
the roof to descend (Fig 4). If intra-abdominal
pressure associated with pathologic processes is
greater than the resistant effect of this mecha-
nism, a hernia may develop.
US Technique
for Evaluation of the IC
Because US can facilitate real-time imaging during
dynamic patient maneuvers, it offers substantial
advantages in evaluation of the IC compared with
other cross-sectional imaging modalities such as
computed tomography (CT) and magnetic reso-
Figure 3.  Diagram of the IC and
its contents. The deep inguinal
ring is formed by the transversalis
fascia, and the IC is lined by the
same layers that line the abdomi-
nal wall. The external superficial
ring is a triangular opening in the
oblique aponeurosis. The inferior
epigastric artery (a.) and vein (v.)
originate from the external iliac
artery and vein and lie medial to
the internal inguinal ring. The lo-
cations of the abdominal wall her-
nias in relation to the IC are as fol-
lows: The indirect inguinal hernias
lie lateral to the inferior epigastric
arteries (1); the direct inguinal her-
nias lie medial and inferior to the
inferior epigastric vessels (2); the
femoral hernias lie inferior and me-
dial to the femoral vessels (3); and
the spigelian hernias lie lateral to
the rectus abdominus muscle (4).
Figure 4.  Diagram of the walls of the IC. The
anterior wall is formed by the aponeuroses of the
external and internal oblique muscles. The poste-
rior wall is formed by the transversalis fascia and
conjoint tendon, a medial juncture of the internal
oblique and transversalis fasciae at the pectineal
line. The roof, or superior wall, is formed by the
aponeuroses of the internal oblique and trans-
versus abdominis muscles. The floor, or inferior
wall, of the IC is formed by the inguinal liga-
ment, a folded-up border of the external oblique
aponeurosis.
nance (MR) imaging, and provocative maneuvers
may aid in visualization of pathologic processes
of the IC—such as reducible hernias and vari-
coceles—that can be missed with static imaging
alone. However, in some instances, CT and MR
imaging may reveal important additional informa-
tion, especially if a large field of view is required or
an abdominal extension must be assessed.
US evaluation of the IC should be optimized
on the basis of the clinical question being
addressed. For most applications, a high-
frequency (ie, 10–12-MHz) linear transducer
2032  November-December 2016 radiographics.rsna.org

Figure 5.  Diagrams of the contents of the IC

in male and female individuals. In male individu-
als, the IC contains the ilioinguinal nerve and
spermatic cord. The spermatic cord contains
the genital branch of the genitofemoral nerve
(from the lumbar plexus); vas deferens and vas
deferens artery (a branch of the inferior vesicle
artery); testicular artery, which originates from
the infrarenal aorta; testicular veins (pumpini-
form plexus), with the left testicular vein drain-
ing into the left renal vein and the right testicular
vein draining directly into the inferior vena cava;
cremasteric artery (a branch of the inferior epi-
gastric artery); lymphatic vessels; and connective
tissue. The external and internal spermatic fas-
ciae and the cremasteric fascia and muscle cover
the spermatic cord. In female individuals, the IC
contains the ilioinguinal nerve, round ligament,
and lymphatic vessels.

Figure 6.  Diagram illustrates the imag-

ing landmarks used for localization of the
deep inguinal ring of the IC, as shown on
the transverse view through the right side
of the abdomen. The deep inguinal ring
is lateral to the origins of the inferior epi-
gastric artery (IEA) and inferior epigastric
vein (IEV). These vessels are posterior to
the lateral border of the rectus abdominis
muscle, approximately 2 cm below the
umbilicus. ASIS = anterior superior iliac
spine, EIA = external iliac artery, EIV = ex-
ternal iliac vein, ST = soft tissues.

is used. Low-frequency (ie, 3–5-MHz) curved
transducers are reserved for examination of larger
patients or cases in which additional depth is re-
quired for a complete evaluation. The acquisition
of comparison views of the contralateral side is
advised when symptoms are focal and no defini-
tive US findings are discovered (9).
Identification of the IC at US is based primar-
ily on localization of the deep inguinal ring, which
is just lateral and slightly cephalic to the origins
of the inferior epigastric vessels, which are best
identified by placing the transducer on the short
axis relative to the rectus abdominis muscle, about
2 cm inferior to the umbilicus. The transducer is
then moved caudally until the inferior epigastric
vessels (two veins and one artery) are seen ly-
ing just deep to the lateral border of the rectus
abdominis muscle (Fig 6). Subsequently, the
vessels are tracked inferolaterally to their origin
at the external iliac vessels (Movie 1) (10). Once
RG  •  Volume 36  Number 7 Revzin et al  2033

Figure 7.  US identification of the IC in a 53-year-old man. (a) Axial oblique color Doppler US image obtained with the trans-
ducer on the long axis relative to the IC with the patient at rest shows the deep inguinal ring as an opening in the peritoneum
(black arrows) that allows passage of the spermatic cord and vessels into the IC (long white arrows). The inferior epigastric vessels
(short white arrows) are located deep to the IC. (b) Sagittal gray-scale US image obtained with the transducer on the short axis
relative to the IC while the patient performed the Valsalva maneuver shows a soft-tissue rim (short arrows) outlining the contents
of the IC. Note the prominent vascular structures and fat infiltration (F) along the cord. The vas deferens (long arrow) also is seen.

Figure 8.  US anatomy of the con-

tents of the spermatic cord in a
46-year-old man. Sagittal color Dop-
pler US image demonstrates the nor-
mal vas deferens (white arrowhead)
as a hypoechoic tubular structure with
linear reflectors in the spermatic cord
(black arrowheads). The vas deferens
is 1.5 mm in diameter. The testicular
vessels (black arrows) are adjacent to
the vas deferens. The spermatic cord is
slightly more hypoechoic than the rest
of the IC contents. The IC is outlined
by the white arrows.

may help in identifying the contents of the cord

the deep inguinal ring is located on the short axis,
the transducer can be angled along the expected
course of the IC, slightly cranial and parallel to
the medial half of the inguinal ligament (Movie
1). The inguinal ligament characteristically ap-
pears on US images as an echogenic cord extend-
ing between the anterior superior iliac spine and
the pubic tubercle, a major bone landmark of
the inguinal region (7). Images are acquired in a
sagittal oblique plane on the short axis relative to
the IC and in an axial oblique plane on the long
axis relative to the IC (Fig 7). The contents of the
IC should be carefully examined by using both
gray-scale and color Doppler US, with the patient
performing the Valsalva maneuver and/or standing
during the examination, to assess for possible her-
nias, varicoceles, and other pathologic processes
(Movie 1) (7). The normal deep inguinal ring
may not be easy to see because it will be collapsed
and closed. Small craniocaudal movements of the
probe while it is oriented in the axial oblique plane
entering the deep ring, further aiding in identifica-
tion of this ring.
The normal contents of the IC have a specific
US appearance. In male patients, the suprascrotal
segment of the vas deferens appears as a cordlike
hypoechoic structure with central parallel linear
reflectors that represent the walls of the lumen
(11). The normal size of the vas deferens is 1–3
mm in anteroposterior diameter. At color Dop-
pler US, the testicular artery and pampiniform
plexus are readily visualized as tubular vessels
coursing along the IC. The spermatic cord, con-
taining the vas deferens and testicular vessels, is
relatively hypoechoic compared with the echo-
genic fat in the IC (Fig 8). The US appearance
of the IC may vary according to the extent of fat
infiltration along the cord. Echogenic infiltrating
fat is seen along the spermatic cord throughout
the course of the IC and is continuous with the
peritoneum cranially; this finding helps to differ-
entiate benign fat infiltration from a fat-contain-
ing mass such as a lipoma (8).
2034  November-December 2016 radiographics.rsna.org
Hernia
An inguinal hernia is a protrusion of the intra-
abdominal structures into the IC. There are two
major types of inguinal hernias: the indirect type,
which represents 50% of all inguinal hernias, and
the direct type, which represents up to 25% of
these protrusions (12). Up to 6.8% of patients are
found to have combined direct and indirect hernias
(13). Although femoral hernias also are considered
groin hernias, they do not involve the IC.
An indirect inguinal hernia occurs when abdom-
inal contents protrude through the deep inguinal
ring and course anteromedially to the spermatic
cord in the IC (Movie 2). The hernia contents
emerge by way of the superficial ring and often
descend into the scrotum or labia majora (5).
Indirect inguinal hernias are more common in
men and are considered to be congenital, as 90%
of cases are associated with a patent PV (14,15).
They occur most commonly on the right side.
Direct hernias are not congenital and tend to
occur in older individuals as a result of relaxation of
the abdominal wall musculature and thinning of the
fascia. They are commonly bilateral. Any condi-
tion that results in either increased intra-abdominal
pressure or abnormal collagen may cause devel-
opment of a direct inguinal hernia. Risk factors
include chronic obstructive pulmonary disease,
heavy lifting, ascites, coughing, peritoneal dialysis,
smoking, and collagen-vascular disease. Direct in-
guinal hernias enter the IC through a defect in the
conjoint aponeurosis of the posterior wall of the IC.
US has an essential role in accurate diagnosis
and evaluation of inguinal hernias and high ac-
curacy in detection of both clinically suspected and
occult hernias; however, it is operator dependent.
The type of inguinal hernia can be determined at
US by identifying the hernia neck and its relation-
ship to the inferior epigastric vessels, and observing
the characteristic movement of the contents of the
hernia with respect to the transducer at provoca-
tive maneuvering (5). The deep inguinal ring is the
neck of an indirect inguinal hernia and is located
lateral to the origin of the inferior epigastric vessels
(Movie 3). The neck of a direct inguinal hernia
lies medial to the inferior epigastric vessels within
the Hesselbach triangle (Fig 9). Because direct
inguinal hernias can occur anywhere in the Hes-
selbach triangle, the entire triangle should be
interrogated incrementally by using the Valsalva
maneuver. Surveillance for possible hernias should
be performed throughout the entire maneuver, as
augmentation of the hernia sac can be observed
during the positive-pressure and relaxation phases
of the Valsalva maneuver. The contents of a direct
hernia sac will move toward the US transducer.
The Valsalva maneuver–induced movement of an
indirect inguinal hernia is more complex than that
Figure 9.  Direct inguinal hernia in a 52-year-old man
with groin pain. A large fat- and bowel-containing her-
nia sac (H) is located medial to the inferior epigastric
vessels (arrows) in the Hesselbach triangle. EIA = exter-
nal iliac artery, EIV = external iliac vein. The hernia sac is
not reducible when the patient is at rest.
of a direct hernia. At the level of the deep inguinal
ring, the indirect hernia contents will move toward
the transducer. Once the contents are in the canal,
they will move along the axis of the IC anteromedi-
ally and inferiorly. When the hernia sac emerges
from the superficial ring, the hernia contents will
again move toward the transducer. The charac-
teristic movement of the hernia contents might
not be detected if the patient is unable to perform
the Valsalva maneuver adequately or the hernia
contents are incarcerated. Having the patient stand
upright or using other provocative maneuvers may
help induce herniation. A potential pitfall in detec-
tion of hernias is related to the normal movement
of the spermatic cord, which when observed during
the Valsalva maneuver is considered a sign of an
indirect inguinal hernia (Movie 4). A lack of disten-
sion of the IC during the Valsalva maneuver while
scanning on the short axis relative to the IC should
help to avoid this misdiagnosis. Another potential
pitfall is misinterpretation of abdominal wall move-
ment as a direct inguinal hernia. The general rule
is that at Valsalva maneuvering, the abdominal wall
will move as one unit, with no translation of the
presumed hernia content separately and anterior to
the inferior epigastric vessels (5).
The hernia sac can contain a variety of intra-
abdominal structures such as mesenteric fat, the
small bowel, the ascending and/or descending
colon, the urinary bladder, ovaries, the appendix,
and ureters. The contents of the hernia sac may
become incarcerated or strangulated. A hernia
is considered to be incarcerated or irreducible if
the contents cannot return to the abdomen either
RG  •  Volume 36  Number 7 Revzin et al  2035

Figures 10, 11.  (10) Spontaneously reducible inguinal hernia in a 3-month-old boy who presented with a lump in the right groin
area. (a) Sagittal gray-scale US image obtained during the Valsalva maneuver shows a large hernia sac (white arrows) in the IC; the
sac contains a loop of small bowel (*). Note the neck (black arrows) of the hernia. (b) Transverse gray-scale US image obtained with
the patient at rest shows a nearly complete spontaneous reduction of the hernia. Only a small amount of omental fat remains in the
residual hernia (arrows). (11) Nonreducible, or incarcerated, indirect inguinal hernia containing a loop of bowel in a 5-year-old girl
who presented with abdominal pain. Sagittal gray-scale US image demonstrates a loop of fluid-filled bowel (arrows) in the hernia sac
(arrowheads). A small amount of surrounding free fluid (*) also is present in the hernia sac. Vascular flow was present in the wall of
the herniated bowel, but no peristalsis was noted (not shown).

prompt the examiner to assess the abdomen for

signs of bowel obstruction.

Management of Inguinal Hernias

spontaneously or with compression (Figs 10, 11)
(Movies 5, 6).
Strangulated hernias are characterized by a
compromised blood supply to the hernia contents.
Signs of potential ischemia include free fluid in
the hernia sac, organ or wall edema, and absence
of bowel peristalsis that results in flaccid bowel.
Color and power Doppler US examinations are
helpful in assessing ischemia of the hernia sac con-
tents. Hyperemia is usually seen during the early
stages of strangulation, and the absence of blood
flow is usually seen during the late stages. Swirling
of mesenteric vessels, or the “whirlpool” sign, can
be seen when the contents of the hernia sac abnor-
mally twist on themselves and cause a compromise
of the blood supply to the affected structure (7).
Air in the hernia sac, peritoneal cavity, or bowel
wall (ie, pneumatosis intestinalis) is a sign of bowel
necrosis or perforation (16).
An obstructed hernia is a bowel-containing
hernia that results in obstruction of the bowel
lumen—usually at the hernia neck. Although the
loops of bowel in the hernia sac generally are not
dilated, the presence of bowel in the sac should
Inguinal hernias are most commonly repaired
with placement of a polypropylene-polytetrafluo-
roethylene mesh or mesh plug across the deficient
tissues that lie between the peritoneum and the
transversalis fascia, deep to the IC. At US, a mesh
appears as an echogenic structure, with posterior
acoustic shadowing that results from the US beam
reflection from the surface of the mesh. Deeper
anatomic structures usually are obscured by the
strong posterior shadowing (Fig 12). Use of an
extended field of view may help in identifying
mesh on US images. With older repaired hernias,
a wavy appearance of the mesh may be seen owing
to mesh shrinkage that results from healing and
formation of fibrous tissue or a scar (8,17).
Postoperative Complications
Seromas, Hematomas, and Abscesses
Seroma or hematoma formation is a common com-
plication that occurs after laparoscopic or open her-
nia repair; the incidence of this complication ranges
from 5% to 25% (18). Seromas and hematomas are
most commonly seen after repair of large indirect
hernias or after emergent (as opposed to elec-
tive) hernia repair. Most seromas and hematomas
resolve within 4–6 weeks. Other common causes of
hematomas in the IC include excessive anticoagula-
tion, trauma, and other surgical procedures (19).
Patients may present with an enlarging groin mass.
At US, hematomas may be seen as simple anechoic
fluid collections in the IC or fluid collections with
2036  November-December 2016 radiographics.rsna.org

Figure 12.  Normal appearance

of a mesh plug (MP) in a 45-year-
old man after hernia repair. Trans-
verse oblique US images obtained
with (right) and without (left) Val-
salva maneuvering show strong
posterior acoustic shadowing (*)
from the mesh plug. Note the site
of entry of the mesh into the deep
inguinal ring (arrows). No change
was observed with Valsalva ma-
neuvering; this finding is consis-
tent with an intact mesh plug.

Figure 13.  Postoperative hema-

toma in a 45-year-old man with
scrotal swelling and pain 11 days
after inguinal hernia repair. Sagit-
tal gray-scale montage US image
demonstrates marked distension of
the right IC (arrows) caused by a
complex heterogeneous fluid col-
lection (*), which extends into the
scrotum. The IC is inflamed and
has thickened walls.

thin weblike internal septa (Fig 13). A perioperative Other Complications

hematoma or seroma may be difficult to differenti-
ate from a postoperative abscess, which is a rare
postoperative complication. An abscess usually de-
velops during the late postoperative period, more
than 30 days after the surgery; however, it may
develop earlier (20). On US images, an abscess gen-
erally appears as a complex fluid collection—often
with associated peripheral hyperemia and echogenic
foci, with dirty shadowing indicative of air. When
differentiation of these entities is difficult at US, the
patient’s clinical history can often aid in making the
correct diagnosis. Contrast material–enhanced CT
can be helpful for confirming the diagnosis and bet-
ter evaluating the extent of an abscess.
Hernia Recurrence
Hernias recur in 0.5%–15.0% of patients, and
this recurrence can be caused by a mesh repair
failure such as mesh migration or erosion. On
US images, a persistent hernia sac is usually seen
along the edge of the linear echogenic mesh, and
the posterior acoustic shadowing produced by the
mesh aids in recognition of this sac (Movie 7).
Migrated mesh material may be seen in the sac of
the recurrent hernia (Fig 14).
Infertility can result from vas deferens obstruc-
tion after bilateral inguinal hernia repair. Tes-
ticular ischemia is a rare but serious complica-
tion that occurs after hernia repair; it is usually
attributable to mesh obliteration of the testicular
artery. At US, injury to the vas deferens should
be suspected if the spermatic cord is edematous.
Heterogeneous enlargement of the testis in con-
junction with a high-resistance arterial wave-
form or absent blood flow suggests the presence
of testicular ischemia (21).
Hydrocele
A hydrocele is a serous fluid collection that oc-
curs in the IC, usually as a result of congenital
failure of the PV to obliterate. Congenital hydro-
celes are present in 6% of male infants at delivery
but in fewer than 1% of adults, as most hydro-
celes resolve by 18 months of age. Hydroceles
are typically located anterior and medial to the
spermatic cord. Patients present with a bulge in
the region of the IC. There are two major types
of IC hydrocele: communicating and noncommu-
nicating (Fig 15). With a communicating hydro-
cele, there is communication of fluid between the
RG  •  Volume 36  Number 7 Revzin et al  2037

Figure 14.  Recurrent inguinal hernia, with a migrated mesh and multiple abdominal and extra-abdominal ab-
scesses, in a 34-year-old man 6 days after hernia repair. (a) Sagittal gray-scale US image shows a large right inguinal
hernia sac, demarcated by the wavy white line at the top, that contains heterogeneous fluid collections (*), echo-
genic inflamed fat, loops of small bowel, and echogenic linear material (long arrow) that likely represents the mesh.
A linear echogenic area (short arrows), compatible with migration of the mesh, is seen in the hernia. (b) Coronal
contrast-enhanced CT image of the pelvis shows a crumpled, redundant-appearing plug of mesh (arrows) in the
hernia and an associated fluid collection (*). Multiple intra-abdominal abscesses (not shown) also were present.

Figure 15.  Diagram illustrates the classification of congenital hydroceles. Left: With a noncommunicating encysted hydrocele,
fluid is trapped in the remnant of the PV. Middle: With a noncommunicating funicular hydrocele, the fluid collection in the IC
communicates with the peritoneal cavity; however, there is no communication with the scrotum. Right: With a communicat-
ing (ie, abdominoscrotal) hydrocele, there is communication of fluid between the peritoneal cavity and the scrotum due to
complete patency of the PV.

peritoneal cavity and scrotum due to complete
patency of the PV (Figs 15, 16). These hydroceles
commonly coexist with indirect inguinal hernias.
There are two subtypes of noncommunicating
hydrocele, also termed spermatic cord hydro-
cele: encysted and funicular. With the encysted
subtype, fluid is trapped in the remnant of the
PV—or canal of Nuck in female persons—and
does not communicate with the peritoneal cavity
or scrotum (Figs 15, 17). With the funicular sub-
type, the fluid collection in the IC communicates
with the peritoneal cavity and deep inguinal ring,
but it does not communicate with the scrotum
(Figs 15, 18). Noncommunicating encysted hy-
droceles are more common (22–24).
In patients with elevated intra-abdominal pres-
sure—for example, in association with cirrhotic
or malignant ascites—the PV may reopen and
allow extension of intra-abdominal fluid into the
scrotum and, in turn, cause an acquired commu-
nicating hydrocele.
On US images, both congenital and acquired
hydroceles usually appear as an anechoic fluid
collection with no internal vascular flow. Low-
level echoes may be seen if debris is present in
the fluid. The debris may result from prior infec-
tion, hemorrhage, or trauma or be related to
proteinaceous material or deposition of choles-
terol crystals. Evaluation for possible extension
of fluid into the peritoneum and scrotum can
2038  November-December 2016 radiographics.rsna.org

Figure 16.  Communicating hydrocele

associated with a patent PV in a 59-year-
old man with a right scrotal hydrocele
and ascites due to cirrhosis. Sagittal gray-
scale montage US image demonstrates
tracking of the ascites through the IC (ar-
row), from the peritoneal cavity (P) into
the scrotum. The scrotal hydrocele and
related contents are not shown.

Figure 17.  Noncommunicating (spermatic cord) encysted hydrocele in a 10-month-old boy with a palpable right
inguinal mass. Sagittal gray-scale montage US image shows an anechoic fluid collection (*) along the spermatic cord
in the IC (arrows). The fluid collection is separate from and above the testis (T). No communication with the peritoneal
cavity (P) is seen. The size of the hydrocele did not change with Valsalva maneuvering (not shown).

Figure 18.  Noncommunicating (spermatic cord) funicular hydrocele in a 3-month-old boy with a pal-
pable right inguinal mass. Sagittal gray-scale and color Doppler montage US image shows an anechoic
fluid collection (*) in the IC communicating (arrow) with the peritoneal cavity (P). The fluid does not
extend into the scrotum. This spermatic cord hydrocele increased in size with Valsalva maneuvering (not
shown). LT = left testis.

help determine the correct pathologic variant Varicocele

of hydrocele. The Valsalva maneuver can help
differentiate the encysted and funicular variants,
with the funicular variant demonstrating a larger
size during the maneuver (25). The differential
diagnosis includes a large epididymal cyst that
extends into the IC (Fig 19).
Varicoceles in Male Individuals
Primary or idiopathic varicoceles are associated
with incompetent valves of the pampiniform
plexus, which lead to impaired venous drainage
and subsequent dilatation of the pampiniform
RG  •  Volume 36  Number 7 Revzin et al  2039

Figure 19.  Epididymal cyst extending into the IC in a

59-year-old man with right testicular pain. (a, b) Sagittal
US images show a large anechoic, avascular, loculated fluid
collection (*) that displaces the testis posteriorly (a) and
extends into the IC (arrows in b) cranially (b). (c) Coronal
contrast-enhanced CT image shows a fluid-filled structure
(*) extending into the right IC. There is no fluid in the peri-
toneal cavity.

when the veins are noncompressible and fill only

partially with blood at color Doppler US (Fig 20).
Another potential cause of a noncompressible vari-
cocele is a retroperitoneal malignant process (19).

Varicoceles (Round Ligament

plexus veins. Primary varicoceles are more com-
mon on the left side, although bilateral varico-
celes may be found in up to 50% of individuals
(26). Secondary varicoceles are caused by in-
creased pressure in the testicular vein as a result
of intra-abdominal pathologic processes (19,27–
29). It is important to note that isolated right-
sided varicoceles are seen in only 6% of patients,
and if they are detected, the retroperitoneum and
abdomen should be evaluated for any pathologic
process—most commonly a neoplasm. Varico-
celes can also develop as a complication of a prior
vasectomy; the reported incidence of such cases
is 27% (30). Symptoms include a soft palpable
mass in the groin, pain, and/or infertility (31).
On gray-scale US images, varicoceles appear as
multiple serpiginous anechoic tubular structures,
with a “bag of worms” appearance, along the IC.
To establish the diagnosis, the veins of the pampi-
niform plexus should be greater than 2–3 mm in
diameter (2). Conspicuity of the veins increases
with the Valsalva maneuver and in the standing
position (2,32). Partial or complete thrombosis
of a varicocele is common and can be diagnosed
Varices) in Female Individuals
Varicosities arising from the round ligament are
rare, are most commonly seen during pregnancy,
and manifest as acute swelling and pain in the
groin (33,34). The clinical presentation associated
with a round ligament varicocele is similar to that
associated with an inguinal hernia, and the distinc-
tion between these two entities can be difficult.
Gray-scale and color Doppler US examinations aid
in this differentiation and thus help to avoid unnec-
essary surgical intervention. The imaging findings
of round ligament varices are the same as those of
varicoceles in male persons (Fig 21). Varicosities
are usually self-limited and are managed conser-
vatively in pregnant patients since most of them
resolve spontaneously after delivery. However, close
monitoring is required, as rupture and thrombosis
of round ligament varices can occur and result in
intense painful swelling in the groin (33,35).
At imaging, thrombosis of a varicocele should
be suspected if the veins are noncompressible
and no flow signal can be seen. A visible clot
may be seen in the lumen. Surgical management
is reserved for cases of uncontrollable pain, sub-
stantial discomfort from varicocele enlargement,
and/or varicocele rupture and thrombosis. Vari-
coceles can be surgically excised or addressed
with embolization. Decompression of the groin
may result in alleviation of symptoms (36–38).
2040  November-December 2016 radiographics.rsna.org

Figure 20.  Partially thrombosed IC

varicocele in a 21-year-old man after
spermatic cord ligation. Sagittal color
Doppler US image of the right IC
shows a dilated partially thrombosed
varicocele (arrow) that contains inter-
nal echoes and very little detectable
blood flow. An increase in the size of
the vein, measuring greater than 3
mm in diameter, was apparent with
Valsalva maneuvering.

Figure 21.  Round ligament varices in a

19-year-old woman who was 8 months
pregnant and presented with bilateral
groin swelling. Sagittal color Doppler mon-
tage US image of the right groin obtained
with the patient at rest (left) and after the
Valsalva maneuver (right) demonstrates
multiple vessels (arrows) in the IC that
became more prominent with Valsalva
maneuvering. These findings are compat-
ible with varicosities. Similar findings were
present on the left side (not shown).

Testicular Ectopia able to the higher rate of testicular cancer in

Undescended Testes
Undescended testes, or cryptorchidism, is a
result of developmental arrest of the normal de-
scent of the testes into the scrotum; it occurs in
up to 30% of premature infants. The incidence
of cryptorchidism, or maldescended testis, in
full-term neonates is estimated to be between
2.7% and 5.9% at birth, but it decreases to
1.2% or 1.8% by 1 year of age (39). Spontane-
ous descent after the 1st year of life is uncom-
mon. Cryptorchidism can be unilateral (90% of
cases) or bilateral (10% of cases) (40). Unde-
scended testes may be located in the abdomi-
nal cavity or anywhere along the path of their
embryologic descent, including retroperitoneal,
pelvic, inguinal, and subinguinal locations. Up
to 80% of individuals with this condition have
testes in the IC (41–43). Undescended testes
should not be confused with ectopic testes, a
condition in which the testes are located outside
of their normal path of descent and found in
places such as the superficial inguinal pouch,
base of the penis, perineal region, femoral loca-
tions, or anterior abdominal wall (43).
Approximately 90% of undescended testes are
associated with a patent PV, and in up to 50% of
cases, there is a coexisting inguinal hernia (44).
In newborns, the risk for torsion of an unde-
scended testis is higher than the risk for torsion
of a normally positioned testis. This is attribut-
undescended testes. Testicular cancer may cause
twisting of the spermatic cord or a change in the
position of the testis. Individuals with an unde-
scended left testicle in situ have an estimated
two- to eightfold increase in the risk for devel-
oping testicular cancer (45,46). Patients with
undescended testes usually are found to have an
empty scrotal sac, with or without a groin mass.
Nearly 80% of undescended testes are pal-
pable. US has 45% sensitivity, 78% specificity,
and 88% accuracy in the localization of a non-
palpable undescended testis and is more accurate
than clinical examination (47,48). At imaging,
nonpalpable testes can be localized by using the
tracking technique (43). With this technique, the
spermatic cord is used as a guide to find the tes-
tes. Initially, one can identify the spermatic cord
in the IC at the deep inguinal ring by scanning in
a sagittal oblique plane on the short axis relative
to the IC. Once found, the cord can be “tracked”
inferiorly in an attempt to locate the testis along
the path of testicular descent. An intra-abdominal
location of the testes should be suspected in cases
of an inability to find the testes within or distal
to the IC (43). Tracking the cord proximal to the
IC may help to localize intra-abdominal testes. In
cases of intra-abdominal testes, the cord may be
looped within the IC.
At gray-scale US, the echogenicity of an unde-
scended testis may vary. Most cryptorchid testes
are hypoechoic; however, some of them may
RG  •  Volume 36  Number 7 Revzin et al  2041

Figure 22.  Chronic torsion of a left

undescended testis in a 5-year-old boy
with an empty left hemiscrotum. Sag-
ittal color Doppler US image of the left
IC (arrows) shows an oval hypoechoic,
atrophic, undescended testis (*), with
no detectable blood flow in the testic-
ular parenchyma. This finding is most
compatible with prenatal testicular
torsion.

be homogeneously hyperechoic, and coarse or of these treatments. Hormone treatment remains

“eggshell” calcifications may be present. Hetero-
geneity of the testicular parenchyma could be due
to the presence of a testicular neoplasm, and in
these cases, the parenchyma should be carefully
assessed with color and spectral Doppler US.
Detection of a testicular mass in an undescended
testis may be quite challenging.
In general, undescended testes are relatively
small, as compared with normally positioned
testes. Testicular atrophy may also be the sequela
of a previously unrecognized torsion. Color Dop-
pler US aids in assessment of testicular viability
(Fig 22). Concern for possible acute torsion
should always be raised when a patient presents
with acute groin pain and symptoms indicating an
empty scrotum. Although US is the first-line imag-
ing modality for evaluation of testicular torsion,
it has decreased accuracy in evaluation of torsion
in undescended testes. The main signs of tor-
sion include increased testicle size and absence of
detectable blood flow. Torsion should be suspected
if venous blood flow is not detected and arterial
blood flow has a high resistance pattern; these
findings indicate the presence of parenchymal
congestion. It is important to note that coexisting
hernias may impair visualization of undescended
testes, and in these cases, Trendelenburg position-
ing of the patient or manual decompression of the
hernia sac is helpful for improving detection.
In young children, the presence of a testicle in
the IC may also be due to a retractile testis. Up
to 50% of boys younger than 11 years have at
least one retractile testis. The retractile testis can
be maneuvered by means of palpation into the
scrotal sac, whereas an undescended testis can-
not (49). Differentiation of these two entities is
very important, as it affects the chosen treatment
management.
Patients with cryptorchidism can be treated
with hormone therapy, surgery, or a combination
controversial, whereas surgery with inguinal
orchiopexy is a well-established treatment for a
palpable undescended testis (50).
Testicular Dislocation
A testicle in the IC can also result from severe
pelvic trauma. Traumatic force can cause the
testicles to retract into the IC or be dislocated.
Although rare, this occurs as a result of direct
external pressure to the perineum that forces
the testicle out of the scrotum and into the sur-
rounding tissue. The actual incidence of testicu-
lar dislocation is difficult to determine and likely
underreported. Bilateral dislocation is rare, con-
stituting only one-third of all cases of testicular
dislocation (51). Motorcycle accidents—more
specifically, those involving fuel tank injury—are
the most commonly reported mechanism (51).
Gray-scale US and color Doppler US are the
methods of choice for establishing the diagnosis
and assessing testicular viability (Fig 23). Once
testicular dislocation is detected on one side, the
contralateral side also should be evaluated. If
the testicle(s) cannot be identified with US, CT
can be performed to look for dislocation into the
abdominal cavity. Internal dislocation is usu-
ally associated with the presence of an inguinal
hernia. In cases of delayed diagnoses, persistent
dislocation for longer than 1 month has been
associated with diffuse atrophy of the seminifer-
ous tubules, nonoccurrence of spermatogenesis,
and a theoretical increased risk for neoplastic
transformation (52).
Endometriosis
Inguinal endometriosis is a result of ectopic
endometrial glands and stroma in the IC. It
can be found along the round ligament (53),
in inguinal lymph nodes, or embedded in the
walls of an inguinal hernia sac (54–59). Surgical
2042  November-December 2016 radiographics.rsna.org
Figure 23.  Dislocated testis with spermatic cord injury in a
44-year-old man after a motorcycle collision. (a) Transverse
color Doppler US image shows an enlarged hypoechoic, het-
erogeneous, and poorly perfused right spermatic cord (white
arrows), with hyperemia of the adjacent structures. The IC
(black arrows) is mildly enlarged. (b) Sagittal spectral Dop-
pler US image shows the contralateral testis (T) dislocated
into the IC. Normal low-resistance waveforms, indicating
normal perfusion, are present in the dislocated testis. (c) Ax-
ial contrast-enhanced pelvic CT image shows left acetabular
fractures and a left testis (T) dislocated into the IC. A commi-
nuted left acetabular fracture (arrow) is seen.
excision is the treatment of choice, as these
masses can, on rare occasion, transform into
malignancies (59). Ninety-one percent of cases
are associated with coexisting pelvic endome-
triosis (59). The clinical symptoms of inguinal
endometriosis may be nonspecific (60). Pa-
tients present with a painful lump in the groin
and cyclical premenstrual tenderness and/
or swelling. A lobulated or irregularly shaped
hypoechoic mass with or without blood flow
may be seen at US. The presence of blood flow
depends on whether the lesion is in an active
or dormant state (Fig 24). Cystic changes also
may be seen in the mass. US findings are non-
specific, and they may mimic those of a tumor.
The imaging appearance of endometriosis
varies according to the amount of hemorrhagic
change and the degree of fibrosis. Hemosid-
erin deposition in the lesion at MR imaging is
a standard finding of this condition. Charac-
teristic MR imaging findings are high signal
intensity on fat-suppressed T1-weighted images
and low signal intensity on T2-weighted images
(61). The patient’s clinical history may help to
confirm the diagnosis.
Corditis
The spermatic cord is the main occupant of the IC.
When it is inflamed or infected, an associated pain-
ful inguinal mass develops. Corditis, also known
as vasitis, refers to inflammation of the spermatic
cord. Funiculitis refers to inflammation of the
suprascrotal portions of the vas deferens. Corditis
usually results from the retrograde spread of patho-
gens from the prostatic urethra, prostate gland, or
seminal vesicles (62). The most common pathogens
are Escherichia coli and Haemophilus influenzae (63).
US findings include increased size of the spermatic
cord, stranding, a heterogeneous appearance of the
vas deferens, a masslike appearance of the echo-
genic fat, a distended IC, and hyperemia that does
not change at Valsalva maneuvering (Fig 25) (11).
Dilated vessels and the vas deferens may resemble
varicoceles on gray-scale US images. However, dy-
namic US during the Valsalva maneuver and color
Doppler US can aid in differentiating these two
entities. Variable degrees of inflammation may be
seen, depending on the severity of the process (Fig
26). Severe corditis may have a masslike appearance
and result in vascular compromise due to compres-
sion of adjacent vessels. This can lead to testicular
RG  •  Volume 36  Number 7 Revzin et al  2043

Figure 24.  IC endometriosis in a 26-year-old woman with cyclic enlargement of and pain in the right groin area.
(a) Sagittal color Doppler US image shows a poorly defined hypoechoic lesion (arrow) in the IC. This lesion has
internal vascularity. The abnormal area corresponds to the area of pain. (b) Axial T1-weighted MR image shows in-
termediate to high signal intensity in the inguinal lesion (arrow). Note the associated large pelvic endometrioma (E).

Figure 25.  Corditis in a 44-year-old man with a history of type I diabetes mellitus and inguinal pain. Transverse gray-scale (a) and
color Doppler (b) US images show a markedly edematous and hyperemic spermatic cord (oval outline) with a central enlarged vas
deferens (white arrow in a). Note the increased echogenicity of the perispermatic fat (F), which is consistent with inflammation.
Edema is noted in the surrounding soft tissues (black arrows in a).

infarction. Patients are treated with antibiotic
agents, although surgical drainage may be required
for severe cases (62).
Torsion of the Spermatic Cord
Torsion of the spermatic cord is relatively rare,
with the cord twisting occurring most commonly
just distal to the superficial inguinal ring. Given
the proximity of the spermatic cord twisting to
the IC and the associated passive congestion
of the venous structures of the more proximal
aspect of the spermatic cord, patients often pres-
ent with inguinal pain and swelling. Use of an
extended field of view and/or imaging beyond the
IC more distally can facilitate diagnosis of torsion
of the spermatic cord (Movie 8).
Neoplasms
Primary neoplasms can arise from any struc-
tures of the IC, such as connective tissue, nerve
sheaths, muscle, fat, blood vessels, and lymphoid
tissue. Benign neoplasms include entities such as
lipoma (Fig 27), leiomyoma (Fig 28), lymphan-
gioma (Fig 29), and cystadenoma. Malignant en-
tities include sarcoma, leiomyosarcoma, liposar-
coma (Fig 30), rhabdosarcoma, and lymphoma.
US findings of malignant neoplasms are nonspe-
cific and often overlap with their benign counter-
parts. Detailed descriptions of these neoplasms
can be found in related articles (32,64,65).
Metastatic Lymphadenopathy
The IC is a common pathway for the metasta-
sis of remote malignant neoplasms, which can
occur hematogenously, by way of lymphatic
drainage, or by way of local invasion from the
adjacent structures—especially bone. The lym-
phatic drainage system in the inguinal region
comprises the superficial and deep inguinal
lymph nodes (Fig 31). The superficial lymph
2044  November-December 2016 radiographics.rsna.org

Figure 26.  Variable degrees of inflammation of the spermatic cord in three male patients who presented with groin
and scrotal tenderness and swelling. (a) Sagittal color Doppler US image in a 13-year-old boy shows mild hyperemia
of the spermatic cord. The epididymis (E) is enlarged and hyperemic. The arrows outline the IC. (b, c) Sagittal gray-
scale (b) and color Doppler (c) US images in a 62-year-old man show a moderate degree of spermatic cord (S) in-
flammation. Note the enlarged and hyperemic spermatic cord, inflamed fat (F) in the IC, and mildly distended IC (ar-
rows). (d) Sagittal color Doppler US image in a 30-year-old man shows severe inflammation of the spermatic cord (S)
and distension of the IC (arrows).

Figure 27.  Lipoma of the IC in a

50-year-old man who presented
with left testicular swelling. Sagittal
gray-scale US image shows disten-
sion of the left IC, which contains
a large well-circumscribed echo-
genic avascular mass (*) with linear
echogenicities (black arrow) that
represent interfaces of fibrous septa.
No connection of the lipoma to the
retroperitoneal fat was observed at
real-time US.

nodes, comprising approximately 10 nodes,

lie immediately below the inguinal ligament
and receive lymphatic drainage from the penis,
scrotum, perineum, buttocks, vulva, anus,
and abdominal wall below the umbilicus, and
these nodes drain into the deep inguinal lymph
nodes. The deep inguinal lymph nodes are
medial to the femoral vein and comprise about
three to five lymph nodes. They drain superi-
orly to the external iliac lymph nodes, then to
the pelvic lymph nodes, and on to the para-
aortic lymph nodes (66).
At US, metastatic lymph nodes usually are
enlarged, round or have irregular borders, and
RG  •  Volume 36  Number 7 Revzin et al  2045

Figures 28–30.  (28) Leiomyoma of the IC in an 18-year-old woman who presented with an enlarging right groin mass. Sagittal
color Doppler US image shows a lobulated hypoechoic mass (M) with increased vascularity in the IC (arrows). Biopsy revealed an
atypical leiomyoma. (29) Lymphangioma in a 59-year-old woman who presented with a lump in the right groin area. (a) Sagit-
tal color Doppler US image shows a complex heterogeneous cystic mass (arrows) with multiple septa in the right IC. There is no
detectable vascular flow. (b) Correlative axial T2-weighted fat-suppressed MR image shows a multiloculated cystic lesion (arrow)
in the IC. A subtraction MR image enhanced with gadolinium-based contrast material (not shown) showed faint enhancement
of the internal septa. (30) Liposarcoma of the IC in a 66-year-old man who presented with an enlarging scrotal mass. (a) Sagit-
tal gray-scale US image shows a predominantly echogenic heterogeneous avascular mass (*) that has solid components and is
distending the right IC (arrows). The mass extended from the scrotum and displaced the right testis laterally and superiorly (not
shown). (b) Corresponding coronal contrast-enhanced CT image shows a poorly defined fatty mass (M) extending into the right
IC and displacing the right testis (T) superiorly.

heterogeneous or hypoechoic, with variable
vascular flow. A normal echogenic hilum usu-
ally is not apparent. Cystic changes and tiny foci
of echogenicity corresponding to calcifications
should always raise suspicion for pathologic
lymph nodes (Figs 32, 33). When inguinal lymph
node metastases are suspected, US-guided biopsy
can be performed (67,68).
Metastatic lymphadenopathy should be dif-
ferentiated from reactive lymphadenopathy,
which can result from an infectious or inflam-
matory process. Enlarged but benign-appearing
lymph nodes with echogenic hila are typical
US features of reactive lymph nodes (Fig 34).
Common benign causes of lymphadenopathy
include viral infection (in children), cellulitis,
and certain medications. In immunocompro-
mised patients such as those with acquired
immunodeficiency syndrome, the differential
diagnosis may also include activated tuberculo-
sis, cryptococcosis, cytomegalovirus infection,
and toxoplasmosis.
Conclusion
Many pathologic conditions can affect the IC.
To accurately interpret findings and establish
the correct diagnosis, it is essential to have
a thorough knowledge of the regional US-
depicted anatomy, optimal US scanning tech-
niques, and US features of various benign and
2046  November-December 2016 radiographics.rsna.org

Figure 31.  Diagram of lymph

nodes of the inguinal region. The
superficial inguinal lymph nodes
can be divided into three groups:
superomedial (1), superolateral
(2), and inferior inguinal (3). The
deep inguinal lymph nodes (4) are
located at the femoral ring, just
medial to the femoral vein, below
the junction with the great saphe-
nous vein. a. = artery, v. = vein.

Figure 32.  IC metastases from penile cancer in a 50-year-old

man. (a, b) Sagittal gray-scale (a) and color Doppler (b) US im-
ages show enlarged diffusely hypoechoic inguinal lymph nodes
(arrow) with cystic components and without normal fatty hila.
Minimal irregular vascularity is present. (c) Coronal positron
emission tomographic (PET)/CT image shows increased radio-
tracer uptake (arrows) in the bilateral inguinal regions and dis-
tal aspect of the penis.

malignant pathologic conditions that can occur

in the IC. Correlative imaging modalities such
as CT and MR imaging have a complementary
role in evaluation of the IC and aid in assess-
ment of disease extent.

Acknowledgments.—The authors thank Henry Douglas for

preparation of the images, Mark Saba for assistance with the
illustrations, Lei Wang for helping with video recording, Denise
Hersey for assistance with the literature, and Sasha Avinger for
obtaining the US images.
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Disclosures of Conflicts of Interest.—L.M.S. Activities related
tion: dialog between genes and cells. Arch Med Res 2001;32(6):
to the present article: disclosed no relevant relationships. Ac- 553–558.
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RG  •  Volume 36  Number 7 Revzin et al  2047

Figure 33.  Hematogenous spread

of metastatic thymoma to the IC in a
60-year-old man who presented with
groin tenderness. (a) Color Doppler
US image of the IC shows enlarged
round vascular abnormal lymph
nodes (M) with cystic changes (arrow)
and no fatty hila. (b) Axial contrast-
enhanced CT image shows a hetero-
geneous soft-tissue mass (M) in the
mediastinum. There is a mass effect
on the heart. (c) Coronal PET/CT im-
age shows substantial fluorine 18 fluo-
rodeoxyglucose uptake (arrow) along
the right IC. Metastasic thymoma was
confirmed with biopsy.

Figure 34.  Reactive lymph node in a

51-year-old man with lower extremity cel-
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the left groin area shows an enlarged and
elongated benign-appearing lymph node
with a characteristic echogenic hilum (H).

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